VR3370 Project SEARCH Asset Discovery Report



Texas Workforce CommissionVocational Rehabilitation ServicesProject SEARCH Asset Discovery Report FORMTEXT ? FORMTEXT ?Instructions FORMTEXT ?Gather the information to complete the interview questions through Discovery techniques, meeting the customer at his or her home, FORMTEXT ? or taking the customer to locations within the community such as to local shopping malls, music stores, parks, or other venues. FORMTEXT ? The goal is to stimulate participation that will help you learn about the customer’s interests FORMTEXT ?from the customer’s perspective rather than from the perspective of a caregiver or a professional social services employee. FORMTEXT ? As necessary, gather information through interviews with the customer’s Circle of Support. FORMTEXT ?Complete the form electronically (on the computer), making certain all questions and all applicable standards have been met before FORMTEXT ? submitting by fax, encrypted email, or mailing with an invoice for payment. FORMTEXT ?Customer Identification Information FORMTEXT ? Associated service authorization (SA) number: FORMTEXT ?????Date Discovery and Report was initiated: FORMTEXT ?????Date Discovery and Report was finished: FORMTEXT ?????Customer Demographic Information FORMTEXT ? Last name: FORMTEXT ?????First name: FORMTEXT ?????Middle name: FORMTEXT ?????VRS case ID: FORMTEXT ?????Street address: (include apartment and room number, if any) FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Primary contact number: ( FORMTEXT ?????) FORMTEXT ?????Secondary contact number: ( FORMTEXT ?????) FORMTEXT ?????Email address: FORMTEXT ?????Does the customer have a legal representative and/or guardian? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, enter name of the person and his or her contact information: FORMTEXT ?????Dates and Hours Discovery Completed FORMTEXT ? For each week the Discovery is completed, enter the date of Monday through Sunday in the date column. FORMTEXT ?For each day of the week, record the number of hours the customer participated in the Discovery. FORMTEXT ?Total the number of hours that the customer participated in the Discovery. FORMTEXT ? WeekDate(Mon-Sun)MondayTuesdayWednesdayThursdayFridaySaturdaySunday1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????6 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Total number of hours customer participated in Discovery: FORMTEXT ????? Visits with the Customer FORMTEXT ? Enter the date, location, and a summary of each visit with the customer and the Skills Trainer as the Discovery process was completed for this report. FORMTEXT ? Note: Must complete a minimum 4 in person observation sessions in different locations with the customer. FORMTEXT ?Date: FORMTEXT ?????Setting: FORMCHECKBOX Individual FORMCHECKBOX GroupLocation: FORMTEXT ?????Summary of visit: FORMTEXT ?????Date: FORMTEXT ?????Setting: FORMCHECKBOX Individual FORMCHECKBOX GroupLocation: FORMTEXT ?????Summary of visit: FORMTEXT ?????Date: FORMTEXT ?????Setting: FORMCHECKBOX Individual FORMCHECKBOX GroupLocation: FORMTEXT ?????Summary of visit: FORMTEXT ?????Date: FORMTEXT ?????Setting: FORMCHECKBOX Individual FORMCHECKBOX GroupLocation: FORMTEXT ?????Summary of visit: FORMTEXT ?????Date: FORMTEXT ?????Setting: FORMCHECKBOX Individual FORMCHECKBOX GroupLocation: FORMTEXT ?????Summary of visit: FORMTEXT ?????Date: FORMTEXT ?????Setting: FORMCHECKBOX Individual FORMCHECKBOX GroupLocation: FORMTEXT ?????Summary of visit: FORMTEXT ?????Date: FORMTEXT ?????Setting: FORMCHECKBOX Individual FORMCHECKBOX GroupLocation: FORMTEXT ?????Summary of visit: FORMTEXT ?????Date: FORMTEXT ?????Setting: FORMCHECKBOX Individual FORMCHECKBOX GroupLocation: FORMTEXT ?????Summary of visit: FORMTEXT ?????Date: FORMTEXT ?????Setting: FORMCHECKBOX Individual FORMCHECKBOX GroupLocation: FORMTEXT ?????Summary of visit: FORMTEXT ?????Date: FORMTEXT ?????Setting: FORMCHECKBOX Individual FORMCHECKBOX GroupLocation: FORMTEXT ?????Summary of visit: FORMTEXT ?????Additional comments, if any: FORMTEXT ?????Interview Questions FORMTEXT ? Who are the people in your life? FORMTEXT ?????List at least three places where you spend time (for example, church, home, and school). 1. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????List 5 tasks or activities you like.List 5 tasks or activities you dislike.1. FORMTEXT ?????1. FORMTEXT ?????2. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????3. FORMTEXT ?????4. FORMTEXT ?????4. FORMTEXT ?????5. FORMTEXT ?????5. FORMTEXT ?????List your strengths, skills, and talents.List your challenges.1. FORMTEXT ?????1. FORMTEXT ?????2. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????3. FORMTEXT ?????4. FORMTEXT ?????4. FORMTEXT ?????5. FORMTEXT ?????5. FORMTEXT ?????What is your disability? FORMTEXT ?????Do you have any concerns about participating in Project SEARCH? FORMTEXT ?????What is a typical day like for you (in regard to chores, part-time job, bedtime, and so on)? FORMTEXT ?????What are your plans after Project SEARCH? FORMTEXT ?????How do you plan on getting to the Project SEARCH site? FORMTEXT ?????How do you plan on getting to work after Project SEARCH? FORMTEXT ?????If you don’t have your own transportation plan, are their family members or friends who might assist you? FORMTEXT ?????Residential History and Domestic Information FORMTEXT ? Describe the customer’s current living situation. FORMTEXT ?????How long has the customer lived at the current location? FORMTEXT ?????Does the customer plan to remain at this location when he or she gets a job? FORMCHECKBOX Yes FORMCHECKBOX NoIs anything potentially putting this living arrangement at risk? FORMTEXT ?????Home Management Skills: FORMTEXT ?Get reports from Circle of Support members about the customer’s ability to perform chores in the home. FORMTEXT ?Verify the reports through observations of the customer performing the chores, as appropriate, to identify possible transferable work skills. FORMTEXT ?ChoresIndependentPromptingPhysical assistanceWash dishes FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cleaning FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Feed and groom pets FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Laundry FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Meal preparation FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Mop and sweep FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Organize bedroom FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Vacuum FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other (describe): FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Describe the customer’s willingness to perform routine and non-routine activities in his or her current living situation such as cleaning, doing laundry, cooking, and managing personal hygiene. Does the customer enjoy some activities more than others? FORMTEXT ? FORMTEXT ????? Describe the neighborhood in which the customer lives. Describe the general availability of services and supports to the customer. FORMTEXT ?Are there support or safety issues in the neighborhood that may affect the customer’s work hours? FORMTEXT ? FORMTEXT ?????Benefit InformationBe sure to refer to benefits planning information provided by the counselor. FORMTEXT ? Does the customer receive Social Security Disability Insurance (SSDI) on his or her own record? FORMCHECKBOX Yes FORMCHECKBOX NoAmount: $ FORMTEXT ?????Are the Social Security benefits received under a parent’s Social Security number? FORMCHECKBOX Yes FORMCHECKBOX NoAmount: $ FORMTEXT ?????Does the customer receive Social Security Income (SSI)? FORMCHECKBOX Yes FORMCHECKBOX NoAmount: $ FORMTEXT ?????Does the customer receive any of the following? FORMTEXT ?Medicare FORMCHECKBOX Yes FORMCHECKBOX NoMedicaid FORMCHECKBOX Yes FORMCHECKBOX NoSNAP FORMCHECKBOX Yes FORMCHECKBOX NoAmount: $ FORMTEXT ?????Public assistance FORMCHECKBOX Yes FORMCHECKBOX NoAmount: $ FORMTEXT ?????Additional Comments: FORMTEXT ?????Medical History FORMTEXT ? What medical conditions (for example, seizures, pain, migraines, and/or substance abuse) FORMTEXT ?does the customer exhibit that must be addressed as an employment plan is developed? FORMTEXT ? Is the customer taking any medication? If so, what and when? FORMTEXT ? FORMTEXT ?????What triggers, antecedents, and/or stressors have interfered with the customer’s achievement of personal goals? FORMTEXT ? FORMTEXT ?????Are there any strategies that appear to work for the customer in managing stressors and/or behaviors? FORMTEXT ? FORMTEXT ?????Customer’s Volunteer and Work History FORMTEXT ? Describe the customer’s volunteer and work history in detail. Include job duties, hours, and the circumstances surrounding the customer’s leaving a job. FORMTEXT ?????Based on what is known about the customer, did the jobs appear to be a good match for the customer, and why or why not? FORMTEXT ?????Based on these work experiences, what has been learned about the customer’s skills, interests, and potential support needs for new employment? FORMTEXT ?????What preferences does the customer have related to a job? (Check all that apply and describe as appropriate.) FORMTEXT ? FORMCHECKBOX Hours to be worked per week FORMTEXT ????? FORMCHECKBOX Hours to be worked on weekends FORMTEXT ????? FORMCHECKBOX Hours to be worked on weekdays FORMTEXT ????? FORMCHECKBOX Hours available. Describe: FORMTEXT ????? FORMCHECKBOX Wage FORMTEXT ????? FORMCHECKBOX Location of business FORMTEXT ????? FORMCHECKBOX Health Insurance FORMTEXT ????? FORMCHECKBOX Other benefits. Describe: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????List employment opportunities and state their distance from your home. FORMTEXT ? BusinessPossible employment opportunitiesTravel Distance FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Additional comments, if any: FORMTEXT ?????Assessment Summary: Present Level of Functioning Observed by the Skills Trainer FORMTEXT ? Activities of Daily Living Task FORMTEXT ?IndependentPromptingPhysical assistanceAttire appropriate to the occasion FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Grooming appropriate to occasion FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Personal hygiene FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Toileting FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Medication management FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX What environmental modifications or support strategies are in place (if any) to help the customer perform activities of daily living? FORMTEXT ? Include a description of any implications that may affect an internship, job match, and/or support strategies on the job. FORMTEXT ? FORMTEXT ?????Observations of physical activities: FORMTEXT ?Vision challenges: Describe: FORMTEXT ?????Hearing challenges: FORMCHECKBOX Independent FORMCHECKBOX Uses hearing aids FORMCHECKBOX Deaf FORMCHECKBOX Other FORMTEXT ?????Tactile challenges: Describe: FORMTEXT ?????Fine motor function: FORMCHECKBOX Independent FORMCHECKBOX With assistance FORMCHECKBOX Dependent FORMCHECKBOX Other FORMTEXT ?????Gross motor function: FORMCHECKBOX Independent FORMCHECKBOX With assistance FORMCHECKBOX Dependent FORMCHECKBOX Other FORMTEXT ?????Strength: Lifting and carrying: FORMCHECKBOX < 10 lbs. FORMCHECKBOX 10-20 lbs. FORMCHECKBOX 21-30 lbs. FORMCHECKBOX 31-40 lbs. Overall upper extremity function: Describe: FORMTEXT ?????Flexibility: FORMCHECKBOX Bends and kneels FORMCHECKBOX Bends and kneels with restriction Describe: FORMTEXT ?????Endurance: Length of time Customer can work: FORMCHECKBOX <2 hours FORMCHECKBOX 2-3 hours FORMCHECKBOX 3-4 hours FORMCHECKBOX 4-5 hours FORMCHECKBOX 5-6 hours FORMCHECKBOX 6-7 hours FORMCHECKBOX 7-8 FORMCHECKBOX 8 hoursAdditional comments: FORMTEXT ?????Work rate: FORMCHECKBOX Slow pace FORMCHECKBOX Steady and/or average pace FORMCHECKBOX Above average pace FORMCHECKBOX Inconsistent pacePhysical mobility status without assistance: FORMCHECKBOX N/A FORMCHECKBOX Able to walk or move around on level surfaces FORMCHECKBOX Sit and/or stand only FORMCHECKBOX Navigates stairs and minor obstacles FORMCHECKBOX Navigates most environments FORMCHECKBOX Uses assistive device. Describe: FORMTEXT ?????Additional comments: FORMTEXT ?????Wheelchair Mobility: FORMCHECKBOX N/A FORMCHECKBOX Able to propel wheelchair to move around on level surfaces FORMCHECKBOX Navigates wheelchair around minor obstacles FORMCHECKBOX Navigates wheelchair in unlevel environments Additional comments: FORMTEXT ?????Standing tolerance: FORMCHECKBOX < 2 hours FORMCHECKBOX 2-3 hours FORMCHECKBOX 3-4 hours FORMCHECKBOX >4 hoursAdditional comments: FORMTEXT ?????Sitting tolerance: FORMCHECKBOX < 2 hours FORMCHECKBOX 2-3 hours FORMCHECKBOX 3-4 hours FORMCHECKBOX >4 hours Additional comments: FORMTEXT ?????Fatigue tolerance:(the ability to continue to work with stressors) FORMCHECKBOX < 2 hours FORMCHECKBOX 2-3 hours FORMCHECKBOX 3-4 hours FORMCHECKBOX >4 hours Additional comments: FORMTEXT ?????Describe transfer abilities—standing to sitting and sitting to standing: FORMTEXT ?????Describe bending and/or kneeling abilities: FORMTEXT ?????Describe temperature tolerances: FORMTEXT ?????Document physical deficits or abilities that may have implications for internship, job match, and support strategies. FORMTEXT ?????Additional comments, if any: FORMTEXT ?????Observed Cognitive skills FORMTEXT ?Report on each of the following cognitive skills observed throughout the Discovery process by either checking the appropriate box, describing the limitation, or entering appears functional if there is no known limitation. If is not applicable, enter N/A. FORMTEXT ?Functional math: FORMCHECKBOX Simple counting FORMCHECKBOX Simple addition FORMCHECKBOX Simple subtraction FORMCHECKBOX Computational skills FORMCHECKBOX NoneAdditional comments: FORMTEXT ?????Functional reading: FORMCHECKBOX Sight reads words and/or symbols FORMCHECKBOX Reads sentences FORMCHECKBOX Reads paragraphs FORMCHECKBOX Fluent reading FORMCHECKBOX Unable to readAdditional comments: FORMTEXT ?????Time awareness: FORMCHECKBOX Unaware of time and clock function FORMCHECKBOX Tells time but loses track of time easily FORMCHECKBOX Can tell time in hours and minutes FORMCHECKBOX Can tell time and track time Additional comments: FORMTEXT ?????Orientation to space: FORMCHECKBOX Manages within work and desk space FORMCHECKBOX Manages in small room FORMCHECKBOX Manages within several rooms FORMCHECKBOX Manages within a building FORMCHECKBOX Manages within the building and grounds FORMCHECKBOX Manages within communityAdditional comments: FORMTEXT ?????Sequencing of tasks: FORMCHECKBOX Cannot perform tasks in sequence FORMCHECKBOX Performs 2-3 tasks in sequence FORMCHECKBOX Performs 4-6 tasks in sequence FORMCHECKBOX Performs 7 or more tasks in sequenceAdditional comments: FORMTEXT ?????Attention to task and perseverance: FORMCHECKBOX Few prompts and/or low supervision FORMCHECKBOX Intermittent prompts and/or low supervision FORMCHECKBOX Intermittent prompts and/or high supervision FORMCHECKBOX Frequent prompts and/or high supervisionAdditional comments: FORMTEXT ?????Money management: FORMCHECKBOX Recognizes money value FORMCHECKBOX Makes basic change $5 with dollars FORMCHECKBOX Makes basic change<$5 with coins FORMCHECKBOX Makes change with coins and dollars under $20 FORMCHECKBOX Makes change with coins and dollars over $20Additional comments: FORMTEXT ?????Learns best with: FORMCHECKBOX Verbal cues FORMCHECKBOX Visual cues FORMCHECKBOX Written cues FORMCHECKBOX Demonstration FORMCHECKBOX Hand over hand assistance Additional comments: FORMTEXT ?????Rate of independent work: FORMCHECKBOX Slow pace FORMCHECKBOX Inconsistent work pace FORMCHECKBOX Steady, average pace FORMCHECKBOX Above average paceAdditional comments: FORMTEXT ?????Document cognitive deficits or abilities that may have implications for Internship, job match, and support strategies. FORMTEXT ?????Describe the most effective way to teach the customer a new task. Describe the sequence of steps or strategies that work best (for example, demonstrate first and then have the customer try). FORMTEXT ?????Additional comments, if any: FORMTEXT ?????Customer’s responses to social situations observed FORMTEXT ?AvoidsTolerates but uncomfortableToleratesComfortableUnknownMaking eye contact FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Being in public setting FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Interacting with colleagues that the customer knows FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Talking with colleagues that the customer knows FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Talking with colleagues that the customer does not know FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Interacting with authorities (supervisor) FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Talking with authorities FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Being alone FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Being with others in a small group FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Being with others in a large group FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Answering questions when the customer does not know the answer FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Participating in small talk FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Working on tasks with others FORMTEXT ? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Document social deficits or abilities that may have implications for internship, job match, and support strategies. FORMTEXT ?????Additional comments, if any: FORMTEXT ?????Observed Behaviors: FORMTEXT ?Communication FORMCHECKBOX Uses sounds and/or gestures FORMCHECKBOX Speaks unclearly FORMCHECKBOX Uses key words and/or signs FORMCHECKBOX Speaks clearly FORMCHECKBOX Content is not always appropriate FORMCHECKBOX Speaks clearly and content is appropriate FORMCHECKBOX Other (describe): FORMTEXT ?????Initiative FORMCHECKBOX Always seeks work FORMCHECKBOX Waits for directions FORMCHECKBOX Sometimes volunteers FORMCHECKBOX Avoids next task FORMCHECKBOX Other (describe): FORMTEXT ?????Withdrawal of attention FORMCHECKBOX Avoids others and/or isolates FORMCHECKBOX Easily distracted FORMCHECKBOX Shows little interest in activities FORMCHECKBOX Fixates on objects and/or information FORMCHECKBOX Other (describe): FORMTEXT ?????Motivation FORMCHECKBOX Supportive of work FORMCHECKBOX Indifferent about work FORMCHECKBOX Supportive with reservation FORMCHECKBOX Negative about work FORMCHECKBOX Other (describe): FORMTEXT ?????Social Interactions FORMCHECKBOX Rarely interacts FORMCHECKBOX Polite FORMCHECKBOX Appears uncomfortable and/or anxious with strangers FORMCHECKBOX Does not initiate social interactions FORMCHECKBOX Initiates social interactions frequently FORMCHECKBOX Other (describe): FORMTEXT ?????Handling criticism FORMCHECKBOX Resistant and/or argumentative FORMCHECKBOX Withdraws into silence FORMCHECKBOX Ignores and does not change FORMCHECKBOX Accepts and does not change FORMCHECKBOX Accepts and makes required change FORMCHECKBOX Other (describe): FORMTEXT ?????Adapting to change FORMCHECKBOX Needs routine FORMCHECKBOX Adapts to change with great difficulty FORMCHECKBOX Adapts to change with some difficulty FORMCHECKBOX Adapts to change FORMCHECKBOX Other (describe): FORMTEXT ?????Acts and/or speaks aggressively FORMCHECKBOX Frequently FORMCHECKBOX Never FORMCHECKBOX Rarely FORMCHECKBOX With specific individuals or situations (describe): FORMTEXT ????? FORMCHECKBOX Other (describe): FORMTEXT ?????Repetitive behavior FORMCHECKBOX Pacing FORMCHECKBOX Rocking FORMCHECKBOX Twirling fingers FORMCHECKBOX Twitching FORMCHECKBOX Other (describe): FORMTEXT ?????Disruptive and/or socially offensive behavior FORMCHECKBOX Refusing to participate FORMCHECKBOX Pouting FORMCHECKBOX Interrupting FORMCHECKBOX Yelling, screaming FORMCHECKBOX Inappropriate touching FORMCHECKBOX Talking too loudly FORMCHECKBOX Acting defiantly FORMCHECKBOX Talking over others FORMCHECKBOX Inappropriate jokes FORMCHECKBOX Intrusive questions FORMCHECKBOX Clinging FORMCHECKBOX Burping and/or picking nose FORMCHECKBOX Not taking turns FORMCHECKBOX Refusing to follow rules FORMCHECKBOX Laughing or crying for no reason FORMCHECKBOX Refusing to follow requests FORMCHECKBOX Other (describe): FORMTEXT ?????Additional comments, if any: FORMTEXT ?????Are there any potential work environments that need to be avoided for health reasons, triggers for behavior issues, FORMTEXT ? or preferences that must be addressed as a non-negotiable condition for an internship or employment? FORMTEXT ? Document implications for job match and support strategies. FORMTEXT ? FORMTEXT ?????Select the strengths the customer possesses that will support an internship or employment. FORMTEXT ? FORMCHECKBOX Transferable skills FORMCHECKBOX Intelligence and/or cognitive skills FORMCHECKBOX Physical abilities and/or capacity FORMCHECKBOX Stable work history FORMCHECKBOX Personality and/or interpersonal skills FORMCHECKBOX Academic skills FORMCHECKBOX Patterns of work behavior FORMCHECKBOX Family support and/or support system FORMCHECKBOX Community involvementOther strengths: FORMTEXT ?????List the job skills and/or job task identified during informational interviews and skill observations FORMTEXT ? 1. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????4. FORMTEXT ?????5. FORMTEXT ?????6. FORMTEXT ?????7. FORMTEXT ?????8. FORMTEXT ?????9. FORMTEXT ?????10. FORMTEXT ?????Additional comments, if any: FORMTEXT ?????Based on the information you gathered, describe the environment and work culture that would offer the best internship setting for the customer. FORMTEXT ?????Based on the information you gathered, what should be avoided to identify the best internship setting for the customer? FORMTEXT ?????Describe the sources of support (social, communication, learning, environmental, assistive technology, and so on) that may be necessary to promote the customer’s success in an internship. FORMTEXT ?????Additional Comments FORMTEXT ? Additional comments, if any: FORMTEXT ?????Customer Signatures FORMTEXT ?Verification of the customer’s and/or customer’s authorized representative’s satisfaction and service delivery obtained by: FORMTEXT ? FORMCHECKBOX Handwritten signature FORMCHECKBOX Digital signature (See VR-SFP 3.11.1 Documentation and Signatures) FORMCHECKBOX By sending a copy of the document returned with a scanned signature FORMCHECKBOX Unable to obtain signature, describe attempts: FORMTEXT ?????By signing below, I, the customer or authorized representative, agree with the information recorded within the report above. FORMTEXT ? If you are not satisfied, do not sign. Contact your VR counselor. FORMTEXT ?Customer’s signature:X FORMTEXT ?Date Signed: FORMTEXT ?????Customer’s authorized representative’s signature, if anyX FORMTEXT ?Date Signed: FORMTEXT ?????Provider Signatures FORMTEXT ?Skills Trainer FORMTEXT ?By signing below, I certify that: FORMTEXT ? the above dates, times, and services are accurate; FORMTEXT ?I personally facilitated all training, meeting all outcomes required for payment and documented the service, as prescribed in the VR-SFP and service authorization; FORMTEXT ? FORMTEXT ?Verification of the customer’s and/or customer’s authorized representative’s satisfaction and service delivery obtained as stated above; FORMTEXT ?I maintain the staff qualifications required for a Skills Trainer as described in the VRSFP or Service Authorization; and FORMTEXT ?I signed my signature and entered the date below. FORMTEXT ?Typed or Printed name: FORMTEXT ?????Signature: (See VR-SFP 3.11.1 Documentation and Signatures)X FORMTEXT ?Date Signed: FORMTEXT ?????Select all that apply: FORMCHECKBOX UNTWISE Credentialed with ID: FORMTEXT ????? FORMCHECKBOX VR3490-Waiver Proof AttachedDirector (only required for Traditional-Bilateral Contractors) FORMTEXT ?By signing below, I, the Director, certify that: FORMTEXT ? I ensure that the services were provided by qualified staff, met all outcomes required for payment, and services were documented, as prescribed in the VR-SFP and service authorization; FORMTEXT ? FORMTEXT ?I maintain UNTWISE Director credential, as prescribed in VR-SFP; FORMTEXT ? I signed my signature and entered the date below. FORMTEXT ?Director Typed or Printed name: FORMTEXT ?????Director Signature: (See VR-SFP 3.11.1 Documentation and Signatures)X FORMTEXT ?Date Signed: FORMTEXT ?????Select all that apply: FORMTEXT ? FORMCHECKBOX UNTWISE Credentialed with ID: FORMTEXT ????? FORMCHECKBOX VR3490-Waiver Proof AttachedVRS Use Only FORMTEXT ?If any question below is answered no or if the report or supporting documentation is missing or incomplete, return the invoice to the provider with the VR3460. Make a case note to document the results of the review and the date VR3460 was sent to provider, when applicable. FORMTEXT ? FORMTEXT ?Technical Review to Verify Provider Qualifications(Completed by any VR staff such as RA, CSC, VR Counselor) FORMTEXT ?Director’s Credential: FORMTEXT ?UNTWISE website or attached VR3490 verifies, for the dates of service, the director listed above: FORMTEXT ? FORMCHECKBOX maintained or waived the UNTWISE Director Credential FORMCHECKBOX did not hold a valid UNTWISE Director CredentialJob Skills Trainer Credential: FORMTEXT ?UNTWISE website or attached VR3490 verifies, for the dates of service, the Job Skills Trainer listed above: FORMTEXT ? FORMCHECKBOX maintained or waived the required UNTWISE Credential FORMCHECKBOX did not hold a valid UNTWISE CredentialVerification of Service Delivery FORMTEXT ?Technical Review (completed by any VR staff such as RA, CSC, VR Counselor) FORMTEXT ?Verified that the report is accurately completed per form instructions FORMCHECKBOX Yes FORMCHECKBOX NoVerified that the service(s) was provided within service date of SA and as stated in the VR Standards for Providers and/or the SA FORMCHECKBOX Yes FORMCHECKBOX NoWhen applicable, verify a copy of an approved VR3472 is attached to the report? FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX NoVerify the customer’s identification information is recorded on the form. FORMCHECKBOX Yes FORMCHECKBOX NoVerify the customer’s demographic information is recorded on the form. FORMCHECKBOX Yes FORMCHECKBOX NoVerify the date, time, location, and summary of all asset discovery sessions completed with the customer. FORMCHECKBOX Yes FORMCHECKBOX NoVerified the customer’s satisfaction with the training through signature on the form and/or by VR staff member contact with customer FORMCHECKBOX Yes FORMCHECKBOX NoVerified that the appropriate fee(s) was invoiced FORMCHECKBOX Yes FORMCHECKBOX NoPrint staff member(s) names who completed technical review and/or verified the UNTWISE Credentials: FORMTEXT ?1. FORMTEXT ????? Date: FORMTEXT ?????2. FORMTEXT ????? Date: FORMTEXT ?????VR Counselor Review FORMTEXT ?Verified the customer received necessary accommodations, supplies and resources; various instructional approaches were used; and the customer has the ability to use compensatory techniques to increase ability to perform task and skills FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoVerified evidence of at least four asset discovery sessions, held at different locations for a total of at least 20 hours of contact with the customer, either individually or in a group setting. FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoVerified evidence showing that all interview questions were covered and documented. FORMCHECKBOX Yes FORMCHECKBOX NoVerified a description of the customer's abilities is complete and accurate. FORMCHECKBOX Yes FORMCHECKBOX NoBy typing or printing your name, the VRC verifies: FORMTEXT ?completion of the technical review, FORMTEXT ?services provided met the customer’s individual needs, FORMTEXT ?services provided met specifications in the VR-SFP and on the SA, and FORMTEXT ?customer’s or legally authorized representative’s satisfaction with services received. FORMTEXT ? FORMCHECKBOX Approve to pay invoice FORMCHECKBOX Do not approve to pay invoiceVR Counselor: FORMTEXT ????? Date: FORMTEXT ????? ................
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